{"id":1131,"date":"2022-06-21T11:51:29","date_gmt":"2022-06-21T11:51:29","guid":{"rendered":"https:\/\/forms.dive.gr\/?page_id=1131"},"modified":"2022-06-21T11:51:53","modified_gmt":"2022-06-21T11:51:53","slug":"nehp","status":"publish","type":"page","link":"https:\/\/forms.dive.gr\/index.php\/nehp\/","title":{"rendered":"no elementor home page"},"content":{"rendered":"\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-69 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-69\" data-uid=\"69f456ba80fac\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-69\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-69 forminator-design--flat  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"69\"\r\n\t\t\t\t\r\n\t\t\t\tdata-design=\"flat\"\r\n\t\t\t\t\r\n\t\t\t\t\r\n\t\t\t\t\r\n\t\t\t\tdata-grid=\"open\"\r\n\t\t\t\t\r\n\t\t\t\t\r\n\t\t\t\tstyle=\"display: none;\"\r\n\t\t\t\t\r\n\t\t\t\tdata-uid=\"69f456ba80fac\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-1_69f456ba80fac\" id=\"forminator-form-69__field--select-1_69f456ba80fac-label\" class=\"forminator-label\">Select program<\/label><select id=\"forminator-form-69__field--select-1_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-1\" data-default-value=\"None\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-1_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-1_69f456ba80fac-description\"><option value=\"None\" selected=\"selected\" data-calculation=\"0\">None<\/option><option value=\"Fun-Diver\"  data-calculation=\"0\">Qualified Fun Diver &amp; Snorkeling Adventure<\/option><option value=\"DSD\"  data-calculation=\"0\">Discover Scuba Diving<\/option><option value=\"OWDC\"  data-calculation=\"0\">Diving Courses - Student<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><p>Please choose desired program<\/p>\n<ol>\n<li>FD - Fun Diver &amp; Snorkeling Statement<\/li>\n<li>DSD - Discover Scuba Diving Statement<\/li>\n<li><a href=\"https:\/\/forms.dive.gr\/index.php\/dsd-and-equipment-form\/\" target=\"_blank\" rel=\"noopener\">DSD Test and Equipment Form<\/a><\/li>\n<\/ol>\n<hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Discover Scuba Diving<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Fun Diver<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-1-picker_69f456ba80fac-label\">Reservation Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"01\/05\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"select-29\" class=\"forminator-field-select forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-29_69f456ba80fac\" id=\"forminator-form-69__field--select-29_69f456ba80fac-label\" class=\"forminator-label\">Select Reservation Time <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-69__field--select-29_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-29\" data-default-value=\"9:00\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-29_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-29_69f456ba80fac-description\"><option value=\"\">Please select an option<\/option><option value=\"9:00\" selected=\"selected\" data-calculation=\"0\">9:00<\/option><option value=\"12:00\"  data-calculation=\"0\">12:00<\/option><option value=\"14:30\"  data-calculation=\"0\">14:30<\/option><option value=\"17:00\"  data-calculation=\"0\">17:00<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><div id=\"time-4\" class=\"forminator-field-time forminator-col forminator-col-4 \"><label id=\"forminator-field-time-4\" class=\"forminator-label\">Time<\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-4-hours\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><select name=\"time-4-hours\" id=\"forminator-form-69__field--time-4-hours_69f456ba80fac\" class=\"forminator-select2 time-hours \" data-field=\"hours\" aria-describedby=\"forminator-field-time-4_69f456ba80fac-description\" data-default-value=\"\"><option value=\"\" selected=\"selected\">-<\/option><option value=\"0\" >00<\/option><option value=\"1\" >01<\/option><option value=\"2\" >02<\/option><option value=\"3\" >03<\/option><option value=\"4\" >04<\/option><option value=\"5\" >05<\/option><option value=\"6\" >06<\/option><option value=\"7\" >07<\/option><option value=\"8\" >08<\/option><option value=\"9\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><\/select><\/div><\/div><div id=\"time-4-minutes\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><select name=\"time-4-minutes\" id=\"forminator-form-69__field--time-4-minutes_69f456ba80fac\" class=\"forminator-select2 time-minutes \" data-field=\"minutes\" aria-describedby=\"forminator-field-time-4_69f456ba80fac-description\" data-default-value=\"\"><option value=\"\" selected=\"selected\">-<\/option><option value=\"0\" >00<\/option><option value=\"1\" >01<\/option><option value=\"2\" >02<\/option><option value=\"3\" >03<\/option><option value=\"4\" >04<\/option><option value=\"5\" >05<\/option><option value=\"6\" >06<\/option><option value=\"7\" >07<\/option><option value=\"8\" >08<\/option><option value=\"9\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><option value=\"32\" >32<\/option><option value=\"33\" >33<\/option><option value=\"34\" >34<\/option><option value=\"35\" >35<\/option><option value=\"36\" >36<\/option><option value=\"37\" >37<\/option><option value=\"38\" >38<\/option><option value=\"39\" >39<\/option><option value=\"40\" >40<\/option><option value=\"41\" >41<\/option><option value=\"42\" >42<\/option><option value=\"43\" >43<\/option><option value=\"44\" >44<\/option><option value=\"45\" >45<\/option><option value=\"46\" >46<\/option><option value=\"47\" >47<\/option><option value=\"48\" >48<\/option><option value=\"49\" >49<\/option><option value=\"50\" >50<\/option><option value=\"51\" >51<\/option><option value=\"52\" >52<\/option><option value=\"53\" >53<\/option><option value=\"54\" >54<\/option><option value=\"55\" >55<\/option><option value=\"56\" >56<\/option><option value=\"57\" >57<\/option><option value=\"58\" >58<\/option><option value=\"59\" >59<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"time-1\" class=\"forminator-field-time forminator-col forminator-col-12 \"><label id=\"forminator-field-time-1\" class=\"forminator-label\">Time<\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-1-hours\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><select name=\"time-1-hours\" id=\"forminator-form-69__field--time-1-hours_69f456ba80fac\" class=\"forminator-select2 time-hours \" data-field=\"hours\" aria-describedby=\"forminator-field-time-1_69f456ba80fac-description\" data-default-value=\"\"><option value=\"\" selected=\"selected\">-<\/option><option value=\"0\" >00<\/option><option value=\"1\" >01<\/option><option value=\"2\" >02<\/option><option value=\"3\" >03<\/option><option value=\"4\" >04<\/option><option value=\"5\" >05<\/option><option value=\"6\" >06<\/option><option value=\"7\" >07<\/option><option value=\"8\" >08<\/option><option value=\"9\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><\/select><\/div><\/div><div id=\"time-1-minutes\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><select name=\"time-1-minutes\" id=\"forminator-form-69__field--time-1-minutes_69f456ba80fac\" class=\"forminator-select2 time-minutes \" data-field=\"minutes\" aria-describedby=\"forminator-field-time-1_69f456ba80fac-description\" data-default-value=\"\"><option value=\"\" selected=\"selected\">-<\/option><option value=\"0\" >00<\/option><option value=\"1\" >01<\/option><option value=\"2\" >02<\/option><option value=\"3\" >03<\/option><option value=\"4\" >04<\/option><option value=\"5\" >05<\/option><option value=\"6\" >06<\/option><option value=\"7\" >07<\/option><option value=\"8\" >08<\/option><option value=\"9\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><option value=\"32\" >32<\/option><option value=\"33\" >33<\/option><option value=\"34\" >34<\/option><option value=\"35\" >35<\/option><option value=\"36\" >36<\/option><option value=\"37\" >37<\/option><option value=\"38\" >38<\/option><option value=\"39\" >39<\/option><option value=\"40\" >40<\/option><option value=\"41\" >41<\/option><option value=\"42\" >42<\/option><option value=\"43\" >43<\/option><option value=\"44\" >44<\/option><option value=\"45\" >45<\/option><option value=\"46\" >46<\/option><option value=\"47\" >47<\/option><option value=\"48\" >48<\/option><option value=\"49\" >49<\/option><option value=\"50\" >50<\/option><option value=\"51\" >51<\/option><option value=\"52\" >52<\/option><option value=\"53\" >53<\/option><option value=\"54\" >54<\/option><option value=\"55\" >55<\/option><option value=\"56\" >56<\/option><option value=\"57\" >57<\/option><option value=\"58\" >58<\/option><option value=\"59\" >59<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-2_69f456ba80fac\" id=\"forminator-form-69__field--select-2_69f456ba80fac-label\" class=\"forminator-label\">Select Program <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-69__field--select-2_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-2\" data-default-value=\"DSD-Course\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-2_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-2_69f456ba80fac-description\"><option value=\"\">Please select an option<\/option><option value=\"DSD-Course\" selected=\"selected\" data-calculation=\"0\">Discover Scuba Diving Course<\/option><option value=\"DSD-I\"  data-calculation=\"0\">Discover Scuba Diving I<\/option><option value=\"DSD-II\"  data-calculation=\"0\">Discover Scuba Diving II<\/option><option value=\"DSD-III-Boat\"  data-calculation=\"0\">Discover Scuba Diving III Boat<\/option><option value=\"TD\"  data-calculation=\"0\">Try Dive<\/option><option value=\"Bubblemaker\"  data-calculation=\"0\">Bubblemaker<\/option><option value=\"Try-Scuba\"  data-calculation=\"0\">Try Scuba<\/option><option value=\"Snuba\"  data-calculation=\"0\">Snuba<\/option><option value=\"Student-Course\"  data-calculation=\"0\">Student Course<\/option><option value=\"Scuba-Diver\"  data-calculation=\"0\">Scuba Diver<\/option><option value=\"Open-Water-Diver\"  data-calculation=\"0\">Open Water Diver<\/option><option value=\"Advanced\"  data-calculation=\"0\">Advanced Open Water Diver<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-71\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-71_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-71_69f456ba80fac-label\">Please specify<\/label><input type=\"text\" name=\"text-71\" value=\"\" placeholder=\"\" id=\"forminator-field-text-71_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-14\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-14_69f456ba80fac\" id=\"forminator-form-69__field--select-14_69f456ba80fac-label\" class=\"forminator-label\">Select Program <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-69__field--select-14_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-14\" data-default-value=\"1TD-Boat\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-14_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-14_69f456ba80fac-description\"><option value=\"\">Please select an option<\/option><option value=\"1TD-Boat\" selected=\"selected\" data-calculation=\"0\">1 Tank  Boat Dive<\/option><option value=\"1TD-Beach\"  data-calculation=\"0\">1 Tank Beach\/Shore Dive<\/option><option value=\"2TD-Boat\"  data-calculation=\"0\">2 Tank Boat Dive<\/option><option value=\"2TD-Beach\"  data-calculation=\"0\">2 Tank Beach\/Shore Dive<\/option><option value=\"5TD\"  data-calculation=\"0\">5 Tank Dive<\/option><option value=\"5TD-with-Own-Gear\"  data-calculation=\"0\">5 Tank with Own Gear Dive<\/option><option value=\"10TD\"  data-calculation=\"0\">10 Tank Dive<\/option><option value=\"SR-1D\"  data-calculation=\"0\">Scuba Review One Dive<\/option><option value=\"SR-2T\"  data-calculation=\"0\">Scuba Review Two Dives<\/option><option value=\"COD\"  data-calculation=\"0\">Check Out Dive<\/option><option value=\"D-SNA-Boat\"  data-calculation=\"0\">Snorkeling from the boat<\/option><option value=\"SNA-Beach\"  data-calculation=\"0\">Snorkeling from the shore<\/option><option value=\"SNA-Boat\"  data-calculation=\"0\">Snorkeling from the boat with guide<\/option><option value=\"SNA-Passenger\"  data-calculation=\"0\">Snorkeling (without equipment)<\/option><option value=\"BSSA\"  data-calculation=\"0\">Beach Sightseeing with Snorkeling Adventure<\/option><option value=\"Rental\"  data-calculation=\"0\">Rental<\/option><option value=\"FD-1T-own-gear\"  data-calculation=\"0\">Fun Dive 1 Tank (Tank &amp; Weight)<\/option><option value=\"Fun-Dive-1-Tank,-Private-Boat-Trip,-up-to-2-persons\"  data-calculation=\"0\">Fun Dive 1 Tank, Private Boat Trip, up to 2 persons<\/option><option value=\"VIP-FD2T\/2\"  data-calculation=\"0\">Fun Dive 2 Tanks, Private Boat Trip, up to 2 persons<\/option><option value=\"VIP-FD1T\/4\"  data-calculation=\"0\">Fun Dive 1 Tank, Private Boat Trip, up to 4 persons<\/option><option value=\"VIP-FD2T\/4\"  data-calculation=\"0\">Fun Dive 2 Tanks, Private Boat Trip, up to 4 persons<\/option><option value=\"Adv-D\"  data-calculation=\"0\">Adventure Dive<\/option><option value=\"FD-2T-W+R\"  data-calculation=\"0\">Wreck Dive \u2013 Two Tank\/Wreck-reef Dive<\/option><option value=\"WD-1T\"  data-calculation=\"0\">Wreck Dive<\/option><option value=\"CD-1T\"  data-calculation=\"0\">Cavern Dive<\/option><option value=\"ND-1T\"  data-calculation=\"0\">Night-Dive<\/option><option value=\"RNT\"  data-calculation=\"0\">Rental Equipment<\/option><option value=\"RNTF\"  data-calculation=\"0\">Rental Equipment with Wet Suit<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-48\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-48\"><p><strong>How did you book your reservation?<\/strong><\/p>\n<ol>\n<li><strong>Direct:<\/strong> Either on your own or though internet booking on our website<\/li>\n<li><strong>Agent:&nbsp;<\/strong>Through an agent (e.g. Viator, CheckYeti)<\/li>\n<li><strong>Hotel:&nbsp;<\/strong>Through a hotel<\/li>\n<\/ol><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-3_69f456ba80fac\" id=\"forminator-form-69__field--select-3_69f456ba80fac-label\" class=\"forminator-label\">Source <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-69__field--select-3_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-3\" data-default-value=\"Direct\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-3_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-3_69f456ba80fac-description\"><option value=\"\">Please select an option<\/option><option value=\"Direct\" selected=\"selected\" data-calculation=\"0\">Direct<\/option><option value=\"Agent\"  data-calculation=\"0\">Agent<\/option><option value=\"Hotel\"  data-calculation=\"0\">Hotel<\/option><\/select><\/div><\/div><div id=\"select-25\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-25_69f456ba80fac\" id=\"forminator-form-69__field--select-25_69f456ba80fac-label\" class=\"forminator-label\">Select Agent<\/label><select id=\"forminator-form-69__field--select-25_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-25\" data-default-value=\"\" data-placeholder=\"\" data-search=\"true\" aria-labelledby=\"forminator-form-69__field--select-25_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-25_69f456ba80fac-description\"><option value=\"Adge\"  data-calculation=\"0\">Adge<\/option><option value=\"CheckYeti\"  data-calculation=\"0\">CheckYeti<\/option><option value=\"PADI-Travel\"  data-calculation=\"0\">PADI Travel<\/option><option value=\"Viator\"  data-calculation=\"0\">Viator<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><div id=\"select-26\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-26_69f456ba80fac\" id=\"forminator-form-69__field--select-26_69f456ba80fac-label\" class=\"forminator-label\">Select Hotel<\/label><select id=\"forminator-form-69__field--select-26_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-26\" data-default-value=\"\" data-placeholder=\"\" data-search=\"true\" aria-labelledby=\"forminator-form-69__field--select-26_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-26_69f456ba80fac-description\"><option value=\"A-Hotel-Mykonos\"  data-calculation=\"0\">A Hotel Mykonos<\/option><option value=\"Flaskos-Suites\"  data-calculation=\"0\">Flaskos Suites<\/option><option value=\"Riviera\"  data-calculation=\"0\">Riviera<\/option><option value=\"Mykonos-Grand\"  data-calculation=\"0\">Mykonos Grand<\/option><option value=\"Deliades\"  data-calculation=\"0\">Deliades<\/option><option value=\"Petinos\"  data-calculation=\"0\">Petinos<\/option><option value=\"Madalena\"  data-calculation=\"0\">Madalena<\/option><option value=\"Paradise-View\"  data-calculation=\"0\">Paradise View<\/option><option value=\"Super-Paradise\"  data-calculation=\"0\">Super Paradise<\/option><option value=\"Nimbas\"  data-calculation=\"0\">Nimbas<\/option><option value=\"Costa-Hotel\"  data-calculation=\"0\">Costa Hotel<\/option><option value=\"Petinos-Beach-Hotel\"  data-calculation=\"0\">Petinos Beach Hotel<\/option><option value=\"Imperial-Myconian\"  data-calculation=\"0\">Imperial Myconian<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-3_69f456ba80fac-label\">Hotel Room<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"#\" id=\"forminator-field-text-3_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-9_69f456ba80fac-label\">Agent:<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-10_69f456ba80fac-label\">Hotel: <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Transfer: Did we provide your transfer to our Diving Center?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"Yes\" id=\"forminator-field-radio-3-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-3-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"No\" id=\"forminator-field-radio-3-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-3-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"time-3\" class=\"forminator-field-time forminator-col forminator-col-6 \"><label id=\"forminator-field-time-3\" class=\"forminator-label\">Time<\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-3-hours\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--time-3-hours_69f456ba80fac\" id=\"forminator-form-69__field--time-3-hours_69f456ba80fac-label\" class=\"forminator-label\">Hours<\/label><select name=\"time-3-hours\" id=\"forminator-form-69__field--time-3-hours_69f456ba80fac\" class=\"forminator-select2 time-hours \" data-field=\"hours\" aria-describedby=\"forminator-field-time-3_69f456ba80fac-description\" aria-labelledby=\"forminator-form-69__field--time-3-hours_69f456ba80fac-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">-<\/option><option value=\"12\" >12<\/option><option value=\"1\" >01<\/option><option value=\"2\" >02<\/option><option value=\"3\" >03<\/option><option value=\"4\" >04<\/option><option value=\"5\" >05<\/option><option value=\"6\" >06<\/option><option value=\"7\" >07<\/option><option value=\"8\" >08<\/option><option value=\"9\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><\/select><\/div><\/div><div id=\"time-3-minutes\" class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--time-3-minutes_69f456ba80fac\" id=\"forminator-form-69__field--time-3-minutes_69f456ba80fac-label\" class=\"forminator-label\">Minutes<\/label><select name=\"time-3-minutes\" id=\"forminator-form-69__field--time-3-minutes_69f456ba80fac\" class=\"forminator-select2 time-minutes \" data-field=\"minutes\" aria-describedby=\"forminator-field-time-3_69f456ba80fac-description\" aria-labelledby=\"forminator-form-69__field--time-3-minutes_69f456ba80fac-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">-<\/option><option value=\"0\" >00<\/option><option value=\"1\" >01<\/option><option value=\"2\" >02<\/option><option value=\"3\" >03<\/option><option value=\"4\" >04<\/option><option value=\"5\" >05<\/option><option value=\"6\" >06<\/option><option value=\"7\" >07<\/option><option value=\"8\" >08<\/option><option value=\"9\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><option value=\"32\" >32<\/option><option value=\"33\" >33<\/option><option value=\"34\" >34<\/option><option value=\"35\" >35<\/option><option value=\"36\" >36<\/option><option value=\"37\" >37<\/option><option value=\"38\" >38<\/option><option value=\"39\" >39<\/option><option value=\"40\" >40<\/option><option value=\"41\" >41<\/option><option value=\"42\" >42<\/option><option value=\"43\" >43<\/option><option value=\"44\" >44<\/option><option value=\"45\" >45<\/option><option value=\"46\" >46<\/option><option value=\"47\" >47<\/option><option value=\"48\" >48<\/option><option value=\"49\" >49<\/option><option value=\"50\" >50<\/option><option value=\"51\" >51<\/option><option value=\"52\" >52<\/option><option value=\"53\" >53<\/option><option value=\"54\" >54<\/option><option value=\"55\" >55<\/option><option value=\"56\" >56<\/option><option value=\"57\" >57<\/option><option value=\"58\" >58<\/option><option value=\"59\" >59<\/option><\/select><\/div><\/div><div class=\"forminator-col forminator-col-4\"><div class=\"forminator-field\"><select name=\"time-3-ampm\" id=\"forminator-form-69__field--time-3-ampm_69f456ba80fac\" class=\"forminator-select2 time-ampm \" data-field=\"ampm\" aria-describedby=\"forminator-field-time-3_69f456ba80fac-description\" data-default-value=\"\"><option value=\"am\" >AM<\/option><option value=\"pm\" >PM<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-68\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-68_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-68_69f456ba80fac-label\">Hotel \/ Accommodation (name) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-68\" value=\"\" placeholder=\"\" id=\"forminator-field-text-68_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-69\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-69_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-69_69f456ba80fac-label\">Hotel Room<\/label><input type=\"text\" name=\"text-69\" value=\"\" placeholder=\"#\" id=\"forminator-field-text-69_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-4_69f456ba80fac\" id=\"forminator-form-69__field--select-4_69f456ba80fac-label\" class=\"forminator-label\">Skills Completed<\/label><select id=\"forminator-form-69__field--select-4_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-4\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-4_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-4_69f456ba80fac-description\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-5_69f456ba80fac\" id=\"forminator-form-69__field--select-5_69f456ba80fac-label\" class=\"forminator-label\">Registration<\/label><select id=\"forminator-form-69__field--select-5_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-5\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-5_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-5_69f456ba80fac-description\"><option value=\"Yes\"  data-calculation=\"0\">Yes<\/option><option value=\"No\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-2-picker_69f456ba80fac-label\">Registration Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-2-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"01-05-2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-42\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-42\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/><\/hr>\n<br>\n<div id=\"demobox\"><strong>STUDENT INFOMATION<\/strong><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-47\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-47\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p>&nbsp;<\/p>\n<div id=\"demobox\"><strong>DIVER INFOMATION<\/strong><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-13\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-13_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-first-name-13_69f456ba80fac-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-13-first-name\" placeholder=\"\" id=\"forminator-field-first-name-13_69f456ba80fac\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-13_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-last-name-13_69f456ba80fac-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-13-last-name\" placeholder=\"\" id=\"forminator-field-last-name-13_69f456ba80fac\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-3-picker_69f456ba80fac-label\">Date of Birth <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-3-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-3-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1930\" data-end-year=\"2022\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"01\/01\/1930\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-1_69f456ba80fac-label\">Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-1\" class=\"forminator-field-signature forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-field-signature\"><label class=\"forminator-label\">Participant Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\" aria-describedby=\"forminator-field-ctlSignature69f456bb15472-description\"><span id=\"ctlSignature69f456bb15472_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\"><\/span><div id=\"ctlSignature69f456bb15472_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69f456bb15472\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-1\" value=\"69f456bb15472\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-66\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-66_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-66_69f456ba80fac-label\">Email <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-66\" value=\"\" placeholder=\"\" id=\"forminator-field-text-66_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-4_69f456ba80fac-label\">Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-3 \"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-address-1-city_69f456ba80fac-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_69f456ba80fac\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-3 \"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-state\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-state_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-address-2-state_69f456ba80fac-label\">State\/Province<\/label><input type=\"text\" name=\"address-2-state\" placeholder=\"E.g. New South Wales\" id=\"forminator-field-address-2-state_69f456ba80fac\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"address-3\" class=\"forminator-field-address forminator-col forminator-col-3 \"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-3-country\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--address-3-country_69f456ba80fac\" class=\"forminator-label\">Country <\/label><select name=\"address-3-country\" id=\"forminator-form-69__field--address-3-country_69f456ba80fac\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" data-default-value=\"Greece\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" selected=\"selected\">Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen Arab Rep.\" data-country-code=\"YE\" >Yemen Arab Rep.<\/option><option value=\"Yemen Democratic\" data-country-code=\"YD\" >Yemen Democratic<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><div id=\"address-4\" class=\"forminator-field-address forminator-col forminator-col-3 \"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-4-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-zip_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-address-4-zip_69f456ba80fac-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-4-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-4-zip_69f456ba80fac\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-phone-1_69f456ba80fac-label\">Telephone\/Whatsapp <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69f456ba80fac\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-5_69f456ba80fac-label\">Occupation<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-number-1_69f456ba80fac-label\">Age <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_69f456ba80fac\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"2\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;.&#039;, &#039;digits&#039;: &#039;2&#039;\" type=\"number\" step=\"any\" min=\"1\" max=\"100\" \/><\/div><\/div><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-3 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Sex <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"M\"><input type=\"radio\" name=\"radio-1\" value=\"M\" id=\"forminator-field-radio-1-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-1-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">M<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-1\" value=\"F\" id=\"forminator-field-radio-1-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-1-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-2_69f456ba80fac-label\">Father&#039;s Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"name-12\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-12_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-12_69f456ba80fac-label\">Father&#039;s Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-12\" value=\"\" placeholder=\"\" id=\"forminator-field-name-12_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"text-67\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-67_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-67_69f456ba80fac-label\">Facebook<\/label><input type=\"text\" name=\"text-67\" value=\"\" placeholder=\"\" id=\"forminator-field-text-67_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-13\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-13_69f456ba80fac\" id=\"forminator-form-69__field--select-13_69f456ba80fac-label\" class=\"forminator-label\">How did you find out about us? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-69__field--select-13_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-13\" data-default-value=\"Internet\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-13_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-13_69f456ba80fac-description\"><option value=\"\">Please select an option<\/option><option value=\"Internet\" selected=\"selected\" data-calculation=\"0\">Internet<\/option><option value=\"Hotel\"  data-calculation=\"0\">Hotel<\/option><option value=\"Trip-Advisor\"  data-calculation=\"0\">Trip Advisor<\/option><option value=\"Travel-Agent\"  data-calculation=\"0\">Travel Agent<\/option><option value=\"Walk-By\"  data-calculation=\"0\">Walk By<\/option><option value=\"Signs\"  data-calculation=\"0\">Signs<\/option><option value=\"Advert\"  data-calculation=\"0\">Advert<\/option><option value=\"Publication\"  data-calculation=\"0\">Publication<\/option><option value=\"Past-Customer\"  data-calculation=\"0\">Past Customer<\/option><option value=\"Friend\"  data-calculation=\"0\">Friend<\/option><option value=\"Google\"  data-calculation=\"0\">Google<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-6_69f456ba80fac-label\">Please specify <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-5\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p>\u00a0<\/p>\n<div id=\"demobox\"><strong>Statement of Risks and Liability<\/strong><\/div>\n<p><br \/>I , {name-13-first-name} {name-13-last-name} , hereby affirm that I am aware that skin and scuba diving have inherent risks which may result in serious injury or death. I affirm I have read and understand the Safe Diving Practices and have had any questions answered to my satisfaction. I understand the importance and purposes of these established practices. I recognise they are for my safety and well-being, and that failure to adhere to them can place me in jeopardy when diving. I understand that diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. I further understand that this programme may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with this programme in spite of the absence of a recompression chamber in proximity to the dive site. The information I have provided about my medical history on the Medical Questionnaire is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health conditions. I further understand that skin diving and scuba diving are physically strenuous activities and that l will be exerting myself during this programme. I further state that I am of lawful age and legally competent to sign this Statement of Risks and Liability, or that I have acquired the written consent of my parent or guardian. Neither the teaching instructor(s), Kostas Sgourakis, the facility through which this training is offered, Mykonos Diving Center \/ Dive Adventures, PADI lnternational Ltd., or PADl Americas, lnc., accept any responsibility for any death, injury or other loss suffered or caused by me or resulting from my own conduct or any manner or condition under my control which amounts to my own contributory negligence. ln the absence of any negligence or other breach of duty by the teaching instructor(s) , Kostas Sgourakis, the facility through which this training is offered, Mykonos Diving Center \/ Dive Adventures , PADI lnternational Ltd., or PADl Americas, lnc., my participation in this diving course is entirely at my own risk.<\/p>\n<p><strong>I {name-13-first-name} {name-13-last-name} have fully informed myself of the contents of this Statement of Risks and Liability by reading it before signing it<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p>\u00a0<\/p>\n<div id=\"demobox\"><strong>STATEMENT OF RISKS AND LIABILITY<\/strong><\/div>\n<p>\u00a0<\/p>\n<p><strong>Please read carefully and fill in all blanks before signing.<\/strong><\/p>\n<p>This is a statement in which you are informed of the risks of skin and scuba diving. The statement also sets out the circumstances in which you participate in the diving programme at your own risk.<br \/>Your signature on this statement is required as proof that you have received and read this statement. It is important that you read the contents of this statement before signing it. If you do not understand anything contained in this statement, then please discuss it with your instructor. If you are a minor, a parent or guardian must also sign this<br \/>form.<\/p>\n<p><strong>WARNING Skin and scuba diving have inherent risks, which may result in serious injury or death.<br \/><\/strong>Diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber. Open water diving trips, which are necessary for training and for certification, may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. Skin and scuba diving are physically strenuous activities and you will be exerting yourself during this diving programme. <br \/><strong>You must advise truthfully and fully inform the dive professionals and the facility through which this programme is <\/strong><strong>offered of your medical history.<\/strong><\/p>\n<p><strong>EXCLUSION OF LIABILITY<\/strong><\/p>\n<p>I understand and agree that neither the dive professionals conducting this programme, Kostas Sgourakis, nor the facility through which this programme is conducted, Mykonos Diving Center \/ Dive Adventures, nor PADI International Ltd., nor PADI Americas, Inc., nor their affiliate or subsidiary corporations, nor any of their respective<br \/>employees, officers, agents or assigns (hereinafter referred to as \u201cReleased Parties\u201d) accept any responsibility for any death, injury or other loss suffered or caused by me or resulting from my own conduct or any matter or condition under my control that amounts to my own contributory negligence.<\/p>\n<p>In the absence of any negligence or other breach of duty by the dive professionals conducting this programme, Kostas Sgourakis, the facility through which this programme is offered, Mykonos Diving Centre \/ Dive Adventures, PADI International Ltd., PADI Americas, Inc., and all released entities and released parties as defined above, my participation in this diving programme is entirely at my own risk.<\/p>\n<p><strong>I {name-13-first-name} {name-13-last-name} acknowledge receipt of this Statement and have read all of the terms before signing this Statement.<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-49\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-49\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\">\n<p>&nbsp;<\/p>\n<div id=\"demobox\"><strong>Statement of Risk and Liability\/ Non-agency Acknowledgment Form<\/strong><\/div>\n<p>Please read carefully and fill in all blanks before signing.<\/p>\n<p><strong>Non-Agency Disclosure and Acknowledgment Agreement<\/strong><\/p>\n<p>I understand and agree that PADI Members (\u201cMembers\u201d), including Mykonos Diving Center and\/or any individual PADI Instructors and Divemasters associated with the program in which I am participating, are licensed to use various PADI Trademarks and to conduct PADI training, but are not agents, employees or franchisees of PADI EMEA Ltd., PADI Americas, Inc., or its parent, subsidiary and affiliated corporations (\u201cPADI\u201d). I further understand that Member business activities are independent, and are neither owned nor operated by PADI, and that while PADI establishes the standards for PADI diver training programs, it is not responsible for, nor does it have the right to control, the operation of the Members\u2019 business activities and the day-to-day conduct of PADI programs and supervision of divers by the Members or their associated staff.<\/p>\n<p><strong>Statement of Risk and Liability<\/strong><\/p>\n<p>This is a statement in which you are informed of the risks of snorkeling and skin diving. The statement also sets out the circumstances in which you participate in the PADI Snorkel Guide programme at your own risk. Your signature on this statement is required as proof that you have received and read this statement. It is important that you read the contents of this statement before signing it. If you do not understand anything contained in this statement, then please discuss it with your course instructor.<\/p>\n<p><strong>WARNING:<\/strong><br>Snorkeling and skin diving have inherent risks which may result in serious injury or death. Snorkeling and skin diving are physically strenuous activities and you will be exerting yourself during this programme. You must advise truthfully and fully inform the dive professional and the facility through which this programme is offered of your medical history. Past or present medical conditions may be contraindicative to your participation in this programme. Your snorkel guide training may be conducted at a site that is remote, either by time or distance or both, from professional medical care. If your snorkel guide training is conducted from a boat, there are potential risks for slipping or falling onboard the boat, being cut or struck by a boat while in the water, injuries occurring while getting on or off a boat, and other perils of the sea.<\/p>\n<p><strong>Acceptance of Risk<\/strong><\/p>\n<p>I affirm that I am not currently suffering from a cold or congestion or have an ear infection. I affirm that I do not have a history of seizures, dizziness or fainting; nor a history of heart condition (e.g. cardiovascular disease, angina, heart attack). I further affirm that I do not have a history of respiratory problems such as asthma, emphysema or tuberculosis. I affirm that I am not currently taking medication that carries a warning about any impairment of my physical or mental abilities. I understand and agree that neither the dive professionals conducting this programme, Mykonos Diving Center, nor the facility through which this programme is conducted, Mykonos Diving Center, nor PADI EMEA Ltd., nor PADI Americas, Inc. nor their affiliate or subsidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns accept any responsibility for any death, injury or other loss suffered by me to the extent that it result from my own conduct or any matter or condition under my control that amounts to my own contributory negligence. In the absence of any negligence or other breach of duty by the dive professionals conducting this programme, Mykonos Diving Center, the facility through which this programme is offered, Mykonos Diving Center, PADI EMEA Ltd., PADI Americas, Inc. and all parties referred to above, my participation in this diving programme is entirely at my own risk.<\/p>\n<p>I HAVE FULLY INFORMED MYSELF OF THE CONTENTS OF THIS NON-AGENCY DISCLOSURE AND<br>ACKNOWLEDGMENT AGREEMENT AND STATEMENT OF RISK AND LIABILITY BY READING BOTH BEFORE<br>SIGNING THESE STATEMENTS.<\/p>\n<p><strong>I {name-13-first-name} {name-13-last-name} acknowledge receipt of this Statement and have read all of the terms before signing this Statement.<\/strong><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-2\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label class=\"forminator-label\">Participant Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\" aria-describedby=\"forminator-field-ctlSignature69f456bb17935-description\"><span id=\"ctlSignature69f456bb17935_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\"><\/span><div id=\"ctlSignature69f456bb17935_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69f456bb17935\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-2\" value=\"69f456bb17935\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-4-picker_69f456ba80fac-label\">Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-4-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"01\/05\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-4-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-3\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label class=\"forminator-label\">Signature of Parent\/Guardian (if applicable)<\/label><div class=\"forminator-signature\" data-elementheight=\"180\" aria-describedby=\"forminator-field-ctlSignature69f456bb17aae-description\"><span id=\"ctlSignature69f456bb17aae_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\"><\/span><div id=\"ctlSignature69f456bb17aae_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69f456bb17aae\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-3\" value=\"69f456bb17aae\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-5-picker_69f456ba80fac-label\">Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-5-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"01\/05\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-5-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-12 \"><label class=\"forminator-label forminator-repeater-label\">Certification Info<\/label><div class=\"forminator-all-group-copies forminator-repeater-field\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"select-28\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--select-28_69f456ba80fac\" id=\"forminator-form-69__field--select-28_69f456ba80fac-label\" class=\"forminator-label\">Certification Agency <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-69__field--select-28_69f456ba80fac\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-28\" data-default-value=\"PADI\" data-placeholder=\"Please select an option\" data-search=\"false\" aria-labelledby=\"forminator-form-69__field--select-28_69f456ba80fac-label\" aria-describedby=\"forminator-form-69__field--select-28_69f456ba80fac-description\"><option value=\"\">Please select an option<\/option><option value=\"PADI\" selected=\"selected\" data-calculation=\"0\">PADI<\/option><option value=\"NAUI\"  data-calculation=\"0\">NAUI<\/option><option value=\"SSI\"  data-calculation=\"0\">SSI<\/option><option value=\"CMAS\"  data-calculation=\"0\">CMAS<\/option><option value=\"BSAC\"  data-calculation=\"0\">BSAC<\/option><option value=\"SDI\"  data-calculation=\"0\">SDI<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><div id=\"text-70\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-70_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-70_69f456ba80fac-label\">Please specify <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-70\" value=\"\" placeholder=\"\" id=\"forminator-field-text-70_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-7_69f456ba80fac-label\">Certification Agency<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-8_69f456ba80fac-label\">Level <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"number-2\" class=\"forminator-field-number forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-2_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-number-2_69f456ba80fac-label\">Year Qualified <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-2\" value=\"\" placeholder=\"\" id=\"forminator-field-number-2_69f456ba80fac\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"2\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;.&#039;, &#039;digits&#039;: &#039;2&#039;\" type=\"number\" step=\"any\" min=\"1970\" max=\"2030\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-6\" class=\"forminator-field-date forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-6-picker_69f456ba80fac-label\">Date of Last Dive <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-6-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-6\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-6-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"number-3\" class=\"forminator-field-number forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-3_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-number-3_69f456ba80fac-label\">Total Number of Dives <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-3\" value=\"\" placeholder=\"\" id=\"forminator-field-number-3_69f456ba80fac\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" type=\"number\" step=\"any\" min=\"\" \/><\/div><\/div><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-3 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Dive Check<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"Yes\" id=\"forminator-field-radio-2-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-2-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"No\" id=\"forminator-field-radio-2-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-2-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-4_69f456ba80fac-label\">By<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-41\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-41\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p>&nbsp;<\/p>\n<div id=\"demobox\"><strong>EMERGENCY CONTACT INFORMATION<\/strong><\/div>\n<p><br \/>\n<p>In case of emergency, contact: (Please supply as much information as you can)<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-10\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-10_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-10_69f456ba80fac-label\">Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-10\" value=\"\" placeholder=\"\" id=\"forminator-field-name-10_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"text-62\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-62_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-62_69f456ba80fac-label\">Relationship <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-62\" value=\"\" placeholder=\"\" id=\"forminator-field-text-62_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-63\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-63_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-63_69f456ba80fac-label\">Residence Phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-63\" value=\"\" placeholder=\"\" id=\"forminator-field-text-63_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-64\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-64_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-64_69f456ba80fac-label\">Work Phone<\/label><input type=\"text\" name=\"text-64\" value=\"\" placeholder=\"\" id=\"forminator-field-text-64_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-65\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-65_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-65_69f456ba80fac-label\">Email<\/label><input type=\"text\" name=\"text-65\" value=\"\" placeholder=\"\" id=\"forminator-field-text-65_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-37\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-37\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p>&nbsp;<\/p>\n<div id=\"demobox\"><strong>Diver Medical | Participant Questionnaire<\/strong><\/div>\n<p><br \/>\n<p>Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and\/or dive activities. References to \u201cdiving\u201d on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.<\/p>\n<p><strong>Directions<\/strong><\/p>\n<p><strong>Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.<br \/><\/strong><strong>Note to women<\/strong>: If you are pregnant, or attempting to become pregnant, do not dive.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have had problems with my lungs\/breathing, heart, blood, or have been diagnosed with COVID-19. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-10\" value=\"Yes\" id=\"forminator-field-radio-10-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-10-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-10\" value=\"No\" id=\"forminator-field-radio-10-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-10-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-11\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I am over 45 years of age. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-11-label-1\" for=\"forminator-field-radio-11-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-11\" value=\"Yes\" id=\"forminator-field-radio-11-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-11-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-11-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-11-label-2\" for=\"forminator-field-radio-11-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-11\" value=\"No\" id=\"forminator-field-radio-11-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-11-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-11-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-12\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I struggle to perform moderate exercise (for example, walk 1.6 kilometer\/one mile in 14 minutes or swim 200 meters\/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-12-label-1\" for=\"forminator-field-radio-12-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-12\" value=\"Yes\" id=\"forminator-field-radio-12-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-12-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-12-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-12-label-2\" for=\"forminator-field-radio-12-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-12\" value=\"No\" id=\"forminator-field-radio-12-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-12-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-12-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-13\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have had problems with my eyes, ears, or nasal passages\/sinuses. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-13-label-1\" for=\"forminator-field-radio-13-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-13\" value=\"Yes\" id=\"forminator-field-radio-13-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-13-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-13-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-13-label-2\" for=\"forminator-field-radio-13-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-13\" value=\"No\" id=\"forminator-field-radio-13-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-13-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-13-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-14\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-14-label-1\" for=\"forminator-field-radio-14-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-14\" value=\"Yes\" id=\"forminator-field-radio-14-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-14-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-14-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-14-label-2\" for=\"forminator-field-radio-14-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-14\" value=\"No\" id=\"forminator-field-radio-14-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-14-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-14-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-15\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-15-label-1\" for=\"forminator-field-radio-15-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-15\" value=\"Yes\" id=\"forminator-field-radio-15-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-15-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-15-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-15-label-2\" for=\"forminator-field-radio-15-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-15\" value=\"No\" id=\"forminator-field-radio-15-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-15-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-15-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-16\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I am currently undergoing treatment (or have required treatment within the last fve years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning disability. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-16-label-1\" for=\"forminator-field-radio-16-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-16\" value=\"Yes\" id=\"forminator-field-radio-16-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-16-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-16-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-16-label-2\" for=\"forminator-field-radio-16-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-16\" value=\"No\" id=\"forminator-field-radio-16-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-16-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-16-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-17\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have had back problems, hernia, ulcers, or diabetes. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-17-label-1\" for=\"forminator-field-radio-17-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-17\" value=\"Yes\" id=\"forminator-field-radio-17-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-17-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-17-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-17-label-2\" for=\"forminator-field-radio-17-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-17\" value=\"No\" id=\"forminator-field-radio-17-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-17-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-17-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-18\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have had stomach or intestine problems, including recent diarrhea. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-18-label-1\" for=\"forminator-field-radio-18-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-18\" value=\"Yes\" id=\"forminator-field-radio-18-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-18-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-18-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-18-label-2\" for=\"forminator-field-radio-18-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-18\" value=\"No\" id=\"forminator-field-radio-18-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-18-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-18-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-19\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefoquine\/Lariam). <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-19-label-1\" for=\"forminator-field-radio-19-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-19\" value=\"Yes\" id=\"forminator-field-radio-19-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-19-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-19-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-19-label-2\" for=\"forminator-field-radio-19-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-19\" value=\"No\" id=\"forminator-field-radio-19-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-19-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-19-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Box A - I have\/have had<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-20\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung). <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-20-label-1\" for=\"forminator-field-radio-20-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-20\" value=\"Yes\" id=\"forminator-field-radio-20-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-20-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-20-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-20-label-2\" for=\"forminator-field-radio-20-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-20\" value=\"No\" id=\"forminator-field-radio-20-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-20-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-20-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-21\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity\/exercise. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-21-label-1\" for=\"forminator-field-radio-21-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-21\" value=\"Yes\" id=\"forminator-field-radio-21-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-21-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-21-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-21-label-2\" for=\"forminator-field-radio-21-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-21\" value=\"No\" id=\"forminator-field-radio-21-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-21-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-21-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-22\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-22-label-1\" for=\"forminator-field-radio-22-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-22\" value=\"Yes\" id=\"forminator-field-radio-22-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-22-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-22-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-22-label-2\" for=\"forminator-field-radio-22-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-22\" value=\"No\" id=\"forminator-field-radio-22-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-22-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-22-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-23\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-23-label-1\" for=\"forminator-field-radio-23-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-23\" value=\"Yes\" id=\"forminator-field-radio-23-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-23-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-23-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-23-label-2\" for=\"forminator-field-radio-23-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-23\" value=\"No\" id=\"forminator-field-radio-23-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-23-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-23-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-24\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">A diagnosis of COVID-19 <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-24-label-1\" for=\"forminator-field-radio-24-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-24\" value=\"Yes\" id=\"forminator-field-radio-24-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-24-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-24-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-24-label-2\" for=\"forminator-field-radio-24-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-24\" value=\"No\" id=\"forminator-field-radio-24-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-24-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-24-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-9\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Box B \u2013 I am over 45 years of age AND:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-25\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I currently smoke or inhale nicotine by other means <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-25-label-1\" for=\"forminator-field-radio-25-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-25\" value=\"Yes\" id=\"forminator-field-radio-25-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-25-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-25-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-25-label-2\" for=\"forminator-field-radio-25-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-25\" value=\"No\" id=\"forminator-field-radio-25-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-25-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-25-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-26\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have a high cholesterol level. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-26-label-1\" for=\"forminator-field-radio-26-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-26\" value=\"Yes\" id=\"forminator-field-radio-26-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-26-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-26-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-26-label-2\" for=\"forminator-field-radio-26-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-26\" value=\"No\" id=\"forminator-field-radio-26-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-26-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-26-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-27\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have high blood pressure <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-27-label-1\" for=\"forminator-field-radio-27-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-27\" value=\"Yes\" id=\"forminator-field-radio-27-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-27-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-27-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-27-label-2\" for=\"forminator-field-radio-27-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-27\" value=\"No\" id=\"forminator-field-radio-27-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-27-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-27-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-28\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy). <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-28-label-1\" for=\"forminator-field-radio-28-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-28\" value=\"Yes\" id=\"forminator-field-radio-28-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-28-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-28-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-28-label-2\" for=\"forminator-field-radio-28-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-28\" value=\"No\" id=\"forminator-field-radio-28-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-28-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-28-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-10\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Box C \u2013 I have\/have had:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-29\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Sinus surgery within the last 6 months <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-29-label-1\" for=\"forminator-field-radio-29-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-29\" value=\"Yes\" id=\"forminator-field-radio-29-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-29-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-29-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-29-label-2\" for=\"forminator-field-radio-29-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-29\" value=\"No\" id=\"forminator-field-radio-29-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-29-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-29-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-30\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Ear disease or ear surgery, hearing loss, or problems with balance. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-30-label-1\" for=\"forminator-field-radio-30-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-30\" value=\"Yes\" id=\"forminator-field-radio-30-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-30-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-30-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-30-label-2\" for=\"forminator-field-radio-30-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-30\" value=\"No\" id=\"forminator-field-radio-30-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-30-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-30-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-31\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Recurrent sinusitis within the past 12 months. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-31-label-1\" for=\"forminator-field-radio-31-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-31\" value=\"Yes\" id=\"forminator-field-radio-31-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-31-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-31-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-31-label-2\" for=\"forminator-field-radio-31-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-31\" value=\"No\" id=\"forminator-field-radio-31-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-31-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-31-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-32\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Eye surgery within the past 3 months. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-32-label-1\" for=\"forminator-field-radio-32-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-32\" value=\"Yes\" id=\"forminator-field-radio-32-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-32-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-32-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-32-label-2\" for=\"forminator-field-radio-32-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-32\" value=\"No\" id=\"forminator-field-radio-32-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-32-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-32-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-11\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Box D \u2013 I have\/have had:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-33\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Head injury with loss of consciousness within the past 5 years <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-33-label-1\" for=\"forminator-field-radio-33-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-33\" value=\"Yes\" id=\"forminator-field-radio-33-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-33-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-33-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-33-label-2\" for=\"forminator-field-radio-33-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-33\" value=\"No\" id=\"forminator-field-radio-33-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-33-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-33-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-34\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Persistent neurologic injury or disease. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-34-label-1\" for=\"forminator-field-radio-34-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-34\" value=\"Yes\" id=\"forminator-field-radio-34-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-34-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-34-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-34-label-2\" for=\"forminator-field-radio-34-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-34\" value=\"No\" id=\"forminator-field-radio-34-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-34-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-34-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-35\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Recurring migraine headaches within the past 12 months, or take medications to prevent them. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-35-label-1\" for=\"forminator-field-radio-35-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-35\" value=\"Yes\" id=\"forminator-field-radio-35-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-35-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-35-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-35-label-2\" for=\"forminator-field-radio-35-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-35\" value=\"No\" id=\"forminator-field-radio-35-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-35-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-35-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-36\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Blackouts or fainting (full\/partial loss of consciousness) within the last 5 years <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-36-label-1\" for=\"forminator-field-radio-36-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-36\" value=\"Yes\" id=\"forminator-field-radio-36-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-36-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-36-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-36-label-2\" for=\"forminator-field-radio-36-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-36\" value=\"No\" id=\"forminator-field-radio-36-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-36-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-36-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-37\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Epilepsy, seizures, or convulsions, OR take medications to prevent them. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-37-label-1\" for=\"forminator-field-radio-37-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-37\" value=\"Yes\" id=\"forminator-field-radio-37-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-37-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-37-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-37-label-2\" for=\"forminator-field-radio-37-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-37\" value=\"No\" id=\"forminator-field-radio-37-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-37-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-37-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-12\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Box E \u2013 I have\/have had:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-38\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Behavioral health, mental or psychological problems requiring medical\/psychiatric treatment. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-38-label-1\" for=\"forminator-field-radio-38-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-38\" value=\"Yes\" id=\"forminator-field-radio-38-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-38-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-38-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-38-label-2\" for=\"forminator-field-radio-38-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-38\" value=\"No\" id=\"forminator-field-radio-38-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-38-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-38-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-39\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication\/psychiatric treatment. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-39-label-1\" for=\"forminator-field-radio-39-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-39\" value=\"Yes\" id=\"forminator-field-radio-39-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-39-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-39-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-39-label-2\" for=\"forminator-field-radio-39-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-39\" value=\"No\" id=\"forminator-field-radio-39-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-39-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-39-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-40\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Been diagnosed with a mental health condition or a learning\/developmental disorder that requires ongoing care. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-40-label-1\" for=\"forminator-field-radio-40-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-40\" value=\"Yes\" id=\"forminator-field-radio-40-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-40-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-40-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-40-label-2\" for=\"forminator-field-radio-40-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-40\" value=\"No\" id=\"forminator-field-radio-40-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-40-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-40-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-41\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">An addiction to drugs or alcohol requiring treatment within the last 5 years. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-41-label-1\" for=\"forminator-field-radio-41-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-41\" value=\"Yes\" id=\"forminator-field-radio-41-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-41-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-41-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-41-label-2\" for=\"forminator-field-radio-41-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-41\" value=\"No\" id=\"forminator-field-radio-41-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-41-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-41-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-13\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Box F \u2013 I have\/have had:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-42\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Recurrent back problems in the last 6 months that limit my everyday activity. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-42-label-1\" for=\"forminator-field-radio-42-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-42\" value=\"Yes\" id=\"forminator-field-radio-42-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-42-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-42-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-42-label-2\" for=\"forminator-field-radio-42-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-42\" value=\"No\" id=\"forminator-field-radio-42-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-42-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-42-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-43\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Back or spinal surgery within the last 12 months. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-43-label-1\" for=\"forminator-field-radio-43-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-43\" value=\"Yes\" id=\"forminator-field-radio-43-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-43-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-43-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-43-label-2\" for=\"forminator-field-radio-43-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-43\" value=\"No\" id=\"forminator-field-radio-43-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-43-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-43-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-44\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-44-label-1\" for=\"forminator-field-radio-44-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-44\" value=\"Yes\" id=\"forminator-field-radio-44-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-44-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-44-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-44-label-2\" for=\"forminator-field-radio-44-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-44\" value=\"No\" id=\"forminator-field-radio-44-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-44-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-44-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-45\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">An uncorrected hernia that limits my physical abilities. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-45-label-1\" for=\"forminator-field-radio-45-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-45\" value=\"Yes\" id=\"forminator-field-radio-45-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-45-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-45-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-45-label-2\" for=\"forminator-field-radio-45-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-45\" value=\"No\" id=\"forminator-field-radio-45-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-45-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-45-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-46\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-46-label-1\" for=\"forminator-field-radio-46-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-46\" value=\"Yes\" id=\"forminator-field-radio-46-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-46-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-46-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-46-label-2\" for=\"forminator-field-radio-46-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-46\" value=\"No\" id=\"forminator-field-radio-46-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-46-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-46-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-14\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Box F \u2013 I have\/have had:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-47\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Ostomy surgery and do not have medical clearance to swim or engage in physical activity. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-47-label-1\" for=\"forminator-field-radio-47-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-47\" value=\"Yes\" id=\"forminator-field-radio-47-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-47-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-47-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-47-label-2\" for=\"forminator-field-radio-47-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-47\" value=\"No\" id=\"forminator-field-radio-47-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-47-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-47-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-48\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Dehydration requiring medical intervention within the last 7 days. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-48-label-1\" for=\"forminator-field-radio-48-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-48\" value=\"Yes\" id=\"forminator-field-radio-48-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-48-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-48-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-48-label-2\" for=\"forminator-field-radio-48-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-48\" value=\"No\" id=\"forminator-field-radio-48-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-48-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-48-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-49\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-49-label-1\" for=\"forminator-field-radio-49-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-49\" value=\"Yes\" id=\"forminator-field-radio-49-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-49-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-49-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-49-label-2\" for=\"forminator-field-radio-49-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-49\" value=\"No\" id=\"forminator-field-radio-49-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-49-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-49-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-50\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-50-label-1\" for=\"forminator-field-radio-50-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-50\" value=\"Yes\" id=\"forminator-field-radio-50-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-50-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-50-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-50-label-2\" for=\"forminator-field-radio-50-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-50\" value=\"No\" id=\"forminator-field-radio-50-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-50-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-50-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-51\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Active or uncontrolled ulcerative colitis or Crohn\u2019s disease. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-51-label-1\" for=\"forminator-field-radio-51-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-51\" value=\"Yes\" id=\"forminator-field-radio-51-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-51-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-51-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-51-label-2\" for=\"forminator-field-radio-51-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-51\" value=\"No\" id=\"forminator-field-radio-51-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-51-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-51-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-52\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Bariatric surgery within the last 12 months. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-52-label-1\" for=\"forminator-field-radio-52-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-52\" value=\"Yes\" id=\"forminator-field-radio-52-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-52-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-52-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-52-label-2\" for=\"forminator-field-radio-52-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-52\" value=\"No\" id=\"forminator-field-radio-52-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-52-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-52-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-40\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-40\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p><strong>If you answered NO<\/strong> to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement<br \/>below by signing and dating it.<\/p>\n<p><strong>Participant Statement<\/strong>: I have answered all questions honestly, and understand that I accept responsibility for any consequences<br \/>resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-23\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\" aria-describedby=\"forminator-field-ctlSignature69f456bb19833-description\"><span id=\"ctlSignature69f456bb19833_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\"><\/span><div id=\"ctlSignature69f456bb19833_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69f456bb19833\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-23\" value=\"69f456bb19833\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-44\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-44-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-44-picker_69f456ba80fac-label\">Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-44-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-44\" value=\"01\/05\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-44-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-16\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-16_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-first-name-16_69f456ba80fac-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-16-first-name\" placeholder=\"\" id=\"forminator-field-first-name-16_69f456ba80fac\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-16_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-last-name-16_69f456ba80fac-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-16-last-name\" placeholder=\"\" id=\"forminator-field-last-name-16_69f456ba80fac\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-7_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-7_69f456ba80fac-label\">Participant Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-7\" value=\"\" placeholder=\"\" id=\"forminator-field-name-7_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"date-45\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-45-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-45-picker_69f456ba80fac-label\">Birthdate <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-45-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-45\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-45-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1950\" data-end-year=\"2017\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"01\/01\/1950\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-81\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have had asthma, emphysema or tuberculosis. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-81-label-1\" for=\"forminator-field-radio-81-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-81\" value=\"Yes\" id=\"forminator-field-radio-81-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-81-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-81-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-81-label-2\" for=\"forminator-field-radio-81-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-81\" value=\"No\" id=\"forminator-field-radio-81-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-81-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-81-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-82\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I currently have an ear infection. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-82-label-1\" for=\"forminator-field-radio-82-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-82\" value=\"Yes\" id=\"forminator-field-radio-82-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-82-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-82-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-82-label-2\" for=\"forminator-field-radio-82-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-82\" value=\"No\" id=\"forminator-field-radio-82-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-82-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-82-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-8\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-8_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-8_69f456ba80fac-label\">Instructor Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-8\" value=\"\" placeholder=\"\" id=\"forminator-field-name-8_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"name-17\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-17_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-17_69f456ba80fac-label\">Diving Center <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-17\" value=\"\" placeholder=\"Please insert Mykonos Diving Center\" id=\"forminator-field-name-17_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-39\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-39\"><p>Diver Medical | Medical Examiner\u2019s Evaluation Form<br \/><br \/><strong>{name-13-first-name} {name-13-last-name}<\/strong> | {date-3}<\/p>\n<p>The above-named person requests your opinion of his\/her medical suitability to participate in recreational scuba diving or freediving training or activity. Please visit uhms.org for medical guidance on medical conditions as they relate to diving. Review the areas rele-<br \/>vant to your patient as part of your evaluation.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-95\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">Evaluation Result<\/span><label id=\"forminator-field-radio-95-label-1\" for=\"forminator-field-radio-95-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Approved \u2013 I find no conditions that I consider incompatible with recreational scuba diving or freediving.\"><input type=\"radio\" name=\"radio-95\" value=\"Approved-\u2013-I-find-no-conditions-that-I-consider-incompatible-with-recreational-scuba-diving-or-freediving.\" id=\"forminator-field-radio-95-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-95-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-95-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Approved \u2013 I find no conditions that I consider incompatible with recreational scuba diving or freediving.<\/span><\/label><label id=\"forminator-field-radio-95-label-2\" for=\"forminator-field-radio-95-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Not approved \u2013 I find conditions that I consider incompatible with recreational scuba diving or freediving.\"><input type=\"radio\" name=\"radio-95\" value=\"Not-approved-\u2013-I-find-conditions-that-I-consider-incompatible-with-recreational-scuba-diving-or-freediving.\" id=\"forminator-field-radio-95-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-95-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-95-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Not approved \u2013 I find conditions that I consider incompatible with recreational scuba diving or freediving.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-22\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\" aria-describedby=\"forminator-field-ctlSignature69f456bb1a4b3-description\"><span id=\"ctlSignature69f456bb1a4b3_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\"><\/span><div id=\"ctlSignature69f456bb1a4b3_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69f456bb1a4b3\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-22\" value=\"69f456bb1a4b3\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-43\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-43-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-43-picker_69f456ba80fac-label\">Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-43-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-43\" value=\"01\/05\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-43-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-6_69f456ba80fac-label\">Medical Examiner&#039;s Name<\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"\" id=\"forminator-field-name-6_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-59\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-59_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-59_69f456ba80fac-label\">Clinical Degrees\/Credentials<\/label><input type=\"text\" name=\"text-59\" value=\"\" placeholder=\"\" id=\"forminator-field-text-59_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-5\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-5-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-5-street_address_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-address-5-street_address_69f456ba80fac-label\">Address<\/label><input type=\"text\" name=\"address-5-street_address\" placeholder=\"\" id=\"forminator-field-address-5-street_address_69f456ba80fac\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-5-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-5-city_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-address-5-city_69f456ba80fac-label\">City<\/label><input type=\"text\" name=\"address-5-city\" placeholder=\"\" id=\"forminator-field-address-5-city_69f456ba80fac\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-5-country\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-form-69__field--address-5-country_69f456ba80fac\" class=\"forminator-label\">Country <\/label><select name=\"address-5-country\" id=\"forminator-form-69__field--address-5-country_69f456ba80fac\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" data-default-value=\"Greece\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" selected=\"selected\">Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen Arab Rep.\" data-country-code=\"YE\" >Yemen Arab Rep.<\/option><option value=\"Yemen Democratic\" data-country-code=\"YD\" >Yemen Democratic<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-60\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-60_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-60_69f456ba80fac-label\">Phone<\/label><input type=\"text\" name=\"text-60\" value=\"\" placeholder=\"\" id=\"forminator-field-text-60_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-61\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-61_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-text-61_69f456ba80fac-label\">Email<\/label><input type=\"text\" name=\"text-61\" value=\"\" placeholder=\"\" id=\"forminator-field-text-61_69f456ba80fac\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-43\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-43\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p><strong>Bubblemaker Statement |<\/strong><strong>MEDICAL QUESTIONNAIRE<\/strong><\/p>\n<p><strong>To the participant and parent<\/strong>: Please answer YES or NO to any of the following items to accurately reflect the participant\u2019s past medical history or present medical condition. A YES answer to any of these items requires that a participant obtain written medical approval <strong>before<\/strong> being allowed to participate in scuba diving activities. If this applies, please ask for a Medical Statement (#10063) to take to the physician.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-79\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I am currently suffering from a cold or congestion. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-79-label-1\" for=\"forminator-field-radio-79-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-79\" value=\"Yes\" id=\"forminator-field-radio-79-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-79-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-79-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-79-label-2\" for=\"forminator-field-radio-79-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-79\" value=\"No\" id=\"forminator-field-radio-79-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-79-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-79-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-80\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have a history of respiratory problems or disease. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-80-label-1\" for=\"forminator-field-radio-80-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-80\" value=\"Yes\" id=\"forminator-field-radio-80-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-80-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-80-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-80-label-2\" for=\"forminator-field-radio-80-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-80\" value=\"No\" id=\"forminator-field-radio-80-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-80-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-80-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-83\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have recurrent ear problems, ear disease or surgery. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-83-label-1\" for=\"forminator-field-radio-83-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-83\" value=\"Yes\" id=\"forminator-field-radio-83-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-83-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-83-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-83-label-2\" for=\"forminator-field-radio-83-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-83\" value=\"No\" id=\"forminator-field-radio-83-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-83-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-83-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-84\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have a history of sinus problems. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-84-label-1\" for=\"forminator-field-radio-84-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-84\" value=\"Yes\" id=\"forminator-field-radio-84-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-84-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-84-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-84-label-2\" for=\"forminator-field-radio-84-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-84\" value=\"No\" id=\"forminator-field-radio-84-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-84-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-84-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-85\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have had problems equalizing (popping) my ears with airplane or mountain travel. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-85-label-1\" for=\"forminator-field-radio-85-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-85\" value=\"Yes\" id=\"forminator-field-radio-85-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-85-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-85-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-85-label-2\" for=\"forminator-field-radio-85-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-85\" value=\"No\" id=\"forminator-field-radio-85-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-85-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-85-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-86\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I am diabetic. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-86-label-1\" for=\"forminator-field-radio-86-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-86\" value=\"Yes\" id=\"forminator-field-radio-86-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-86-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-86-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-86-label-2\" for=\"forminator-field-radio-86-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-86\" value=\"No\" id=\"forminator-field-radio-86-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-86-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-86-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-87\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have a history of heart condition (e.g., cardiovascular disease, angina, heart attack). <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-87-label-1\" for=\"forminator-field-radio-87-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-87\" value=\"Yes\" id=\"forminator-field-radio-87-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-87-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-87-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-87-label-2\" for=\"forminator-field-radio-87-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-87\" value=\"No\" id=\"forminator-field-radio-87-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-87-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-87-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-88\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have a history of seizures, dizziness or fainting. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-88-label-1\" for=\"forminator-field-radio-88-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-88\" value=\"Yes\" id=\"forminator-field-radio-88-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-88-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-88-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-88-label-2\" for=\"forminator-field-radio-88-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-88\" value=\"No\" id=\"forminator-field-radio-88-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-88-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-88-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-89\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have a nervous system disorder. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-89-label-1\" for=\"forminator-field-radio-89-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-89\" value=\"Yes\" id=\"forminator-field-radio-89-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-89-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-89-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-89-label-2\" for=\"forminator-field-radio-89-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-89\" value=\"No\" id=\"forminator-field-radio-89-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-89-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-89-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-90\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have behavioural health, mental or psychological disorders (panic attack, fear of closed or open spaces). <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-90-label-1\" for=\"forminator-field-radio-90-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-90\" value=\"Yes\" id=\"forminator-field-radio-90-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-90-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-90-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-90-label-2\" for=\"forminator-field-radio-90-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-90\" value=\"No\" id=\"forminator-field-radio-90-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-90-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-90-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-91\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have recurrent back problems, history of back or spinal surgery. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-91-label-1\" for=\"forminator-field-radio-91-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-91\" value=\"Yes\" id=\"forminator-field-radio-91-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-91-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-91-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-91-label-2\" for=\"forminator-field-radio-91-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-91\" value=\"No\" id=\"forminator-field-radio-91-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-91-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-91-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-92\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I am currently taking prescription medication that carries a warning about impairment of physical and mental abilities (with the exception of anti-malarial). <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-92-label-1\" for=\"forminator-field-radio-92-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-92\" value=\"Yes\" id=\"forminator-field-radio-92-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-92-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-92-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-92-label-2\" for=\"forminator-field-radio-92-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-92\" value=\"No\" id=\"forminator-field-radio-92-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-92-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-92-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-93\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I have recently had an operation or illness. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-93-label-1\" for=\"forminator-field-radio-93-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-93\" value=\"Yes\" id=\"forminator-field-radio-93-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-93-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-93-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-93-label-2\" for=\"forminator-field-radio-93-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-93\" value=\"No\" id=\"forminator-field-radio-93-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-93-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-93-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-94\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">I am under the care of a physician or have a chronic illness. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-94-label-1\" for=\"forminator-field-radio-94-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-94\" value=\"Yes\" id=\"forminator-field-radio-94-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-94-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-94-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-94-label-2\" for=\"forminator-field-radio-94-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-94\" value=\"No\" id=\"forminator-field-radio-94-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-94-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-94-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-44\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-44\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p><strong>BUBBLEMAKER STATEMENT OF RISKS AND LIABILITY<\/strong><\/p>\n<p><strong>Please read carefully and fill in all blanks before signing.<\/strong><\/p>\n<p>This is a statement in which you are informed of the risks of skin and scuba diving. The statement also sets out the circumstances in which your child participates in the diving programme at your child\u2019s own risk.<\/p>\n<p>Your signature on this statement is required as proof that you and your child have received and read this statement. It is important that you read the contents of this statement before signing it. If you do not understand anything contained in this statement, then please discuss it with your child\u2019s instructor.<\/p>\n<p><strong>WARNING<\/strong><\/p>\n<p>Skin and scuba diving have inherent risks which may result in serious injury or death.<\/p>\n<p>Diving with compressed air involves certain inherent risks; decompression sickness, embolism or other hyperbaric injury can occur that require treatment in a recompression chamber and your child will be exposed to these risks. This programme may be conducted at a site which is remote, either by time or distance or both, from such a recompression chamber<\/p>\n<p>Skin and scuba diving are physically strenuous activities and your child will be exerting themselves during this diving programme. You must advise truthfully and fully inform the dive professionals and the facility through which this programme is offered of your child\u2019s medical history.<\/p>\n<p><strong>EXCLUSION OF LIABILITY<\/strong><\/p>\n<p>I understand and agree that neither the dive professionals conducting this programme, nor the facility through which this programme is conducted,<br \/>Mykonos Diving Center, nor PADI International Ltd., nor PADI Americas, Inc., nor their affiliate or subsidiary<br \/>\u00a0orporations, nor any of their respective employees, officers, agents or assigns (hereinafter referred to as \u201cReleased Parties\u201d) accept any responsibility for any death, injury or other loss suffered or caused by me or resulting from my own conduct or any matter or condition under my control that amounts to my own contributory negligence.<br \/>In the absence of any negligence or other breach of duty by the dive professionals conducting this programme, the facility through which this programme is offered, Mykonos Diving Center, PADI International Ltd., PADI Americas, Inc., and all related entities and released parties as defined above, my participation in this diving programme is entirely at my own risk.<\/p>\n<p>I acknowledge receipt of this Statement and have read all of the terms before signing this Statement.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-15\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-15_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-first-name-15_69f456ba80fac-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-15-first-name\" placeholder=\"\" id=\"forminator-field-first-name-15_69f456ba80fac\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-15_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-last-name-15_69f456ba80fac-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-15-last-name\" placeholder=\"\" id=\"forminator-field-last-name-15_69f456ba80fac\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-11\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-11_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-name-11_69f456ba80fac-label\">Participant Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-11\" value=\"\" placeholder=\"\" id=\"forminator-field-name-11_69f456ba80fac\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-24\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\" aria-describedby=\"forminator-field-ctlSignature69f456bb1b306-description\"><span id=\"ctlSignature69f456bb1b306_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\"><\/span><div id=\"ctlSignature69f456bb1b306_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69f456bb1b306\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-24\" value=\"69f456bb1b306\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-46\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-46-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-46-picker_69f456ba80fac-label\">Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-46-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-46\" value=\"01\/05\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-46-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"2010\" data-end-year=\"2040\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"01\/01\/2010\" data-end-date=\"12\/31\/2040\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-25\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label class=\"forminator-label\">Signature of Parent\/Guardian (where applicable)<\/label><div class=\"forminator-signature\" data-elementheight=\"180\" aria-describedby=\"forminator-field-ctlSignature69f456bb1b48f-description\"><span id=\"ctlSignature69f456bb1b48f_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\"><\/span><div id=\"ctlSignature69f456bb1b48f_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69f456bb1b48f\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-25\" value=\"69f456bb1b48f\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-47\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-47-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-47-picker_69f456ba80fac-label\">Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-47-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-47\" value=\"01\/05\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-47-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"2010\" data-end-year=\"2040\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"01\/01\/2010\" data-end-date=\"12\/31\/2040\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><hr style=\"height: 2px;border-width: 0;color: #ccc;background-color: #ccc\" \/>\n<p>&nbsp;<\/p>\n<div id=\"demobox\"><strong>Discover Scuba Diving Knowledge and Safety Review<\/strong><\/div>\n<p><br \/>\n<p>To continue your Discover Scuba Diving Experience, you must complete this review under the directiob of your PADI Proffessional <strong>before<\/strong> getting in the water.<\/p>\n<p>Check the appropriate box in response to each question.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-69\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">1. Upon completing this experience, I will be qualified to dive independently without a certified professional guiding me.<\/span><label id=\"forminator-field-radio-69-label-1\" for=\"forminator-field-radio-69-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-69\" value=\"T\" id=\"forminator-field-radio-69-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-69-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-69-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-69-label-2\" for=\"forminator-field-radio-69-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-69\" value=\"F\" id=\"forminator-field-radio-69-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-69-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-69-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-70\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">2. To equalize my ears and sinus air spaces during descent, I will need to blow gently against pinched nostrils.<\/span><label id=\"forminator-field-radio-70-label-1\" for=\"forminator-field-radio-70-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-70\" value=\"T\" id=\"forminator-field-radio-70-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-70-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-70-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-70-label-2\" for=\"forminator-field-radio-70-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-70\" value=\"F\" id=\"forminator-field-radio-70-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-70-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-70-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-71\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">3. I should equalize every few metre\/few feet while descending<\/span><label id=\"forminator-field-radio-71-label-1\" for=\"forminator-field-radio-71-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-71\" value=\"T\" id=\"forminator-field-radio-71-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-71-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-71-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-71-label-2\" for=\"forminator-field-radio-71-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-71\" value=\"F\" id=\"forminator-field-radio-71-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-71-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-71-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-72\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">4. If I have discomfort in my ears and sinuses during descent, I should continue downward.<\/span><label id=\"forminator-field-radio-72-label-1\" for=\"forminator-field-radio-72-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-72\" value=\"T\" id=\"forminator-field-radio-72-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-72-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-72-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-72-label-2\" for=\"forminator-field-radio-72-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-72\" value=\"F\" id=\"forminator-field-radio-72-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-72-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-72-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-73\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">5. Underwater, I should breath slowly, deeply, continuously and never hold my breath.<\/span><label id=\"forminator-field-radio-73-label-1\" for=\"forminator-field-radio-73-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-73\" value=\"T\" id=\"forminator-field-radio-73-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-73-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-73-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-73-label-2\" for=\"forminator-field-radio-73-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-73\" value=\"F\" id=\"forminator-field-radio-73-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-73-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-73-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-74\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">6. I should add air to my buoyancy control device (BCD) to float at the surface.<\/span><label id=\"forminator-field-radio-74-label-1\" for=\"forminator-field-radio-74-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-74\" value=\"T\" id=\"forminator-field-radio-74-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-74-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-74-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-74-label-2\" for=\"forminator-field-radio-74-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-74\" value=\"F\" id=\"forminator-field-radio-74-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-74-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-74-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-75\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">7. My air gague indicates how much air I have in my cylinder and I must look at it often, and whenever my instructor asks me to.<\/span><label id=\"forminator-field-radio-75-label-1\" for=\"forminator-field-radio-75-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-75\" value=\"T\" id=\"forminator-field-radio-75-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-75-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-75-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-75-label-2\" for=\"forminator-field-radio-75-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-75\" value=\"F\" id=\"forminator-field-radio-75-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-75-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-75-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-76\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">8. I should not touch, tease, or harass an underwater organism since I may harm it or it may harm me.<\/span><label id=\"forminator-field-radio-76-label-1\" for=\"forminator-field-radio-76-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-76\" value=\"T\" id=\"forminator-field-radio-76-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-76-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-76-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-76-label-2\" for=\"forminator-field-radio-76-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-76\" value=\"F\" id=\"forminator-field-radio-76-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-76-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-76-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-77\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f456ba80fac-label\" aria-describedby=\"forminator-radiogroup-69f456ba80fac-description\"><span id=\"forminator-radiogroup-69f456ba80fac-label\" class=\"forminator-label\">9. I should stay close to the PADI Professional during my Discover Scuba Diving experience and signal if something is wrong<\/span><label id=\"forminator-field-radio-77-label-1\" for=\"forminator-field-radio-77-1-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"T\"><input type=\"radio\" name=\"radio-77\" value=\"T\" id=\"forminator-field-radio-77-1-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-77-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-77-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">T<\/span><\/label><label id=\"forminator-field-radio-77-label-2\" for=\"forminator-field-radio-77-2-69f456ba80fac\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-77\" value=\"F\" id=\"forminator-field-radio-77-2-69f456ba80fac\" aria-labelledby=\"forminator-field-radio-77-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-77-69f456ba80fac-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">F<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-38\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-38\"><p>Participant Statement: I have had this Review explained to me and I now understand any questions I may have answered incorrectly. I acknowledge and accept that these practices are intended to increase my safety and comfort during the experience.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-21\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label class=\"forminator-label\">Participant&#039;s Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\" aria-describedby=\"forminator-field-ctlSignature69f456bb1b9d1-description\"><span id=\"ctlSignature69f456bb1b9d1_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\"><\/span><div id=\"ctlSignature69f456bb1b9d1_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature69f456bb1b9d1\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-21\" value=\"69f456bb1b9d1\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-41\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-41-picker_69f456ba80fac\" class=\"forminator-label\" id=\"forminator-field-date-41-picker_69f456ba80fac-label\">Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-41-picker_69f456ba80fac\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-41\" value=\"01\/05\/2026\" placeholder=\"Choose Date\" id=\"forminator-field-date-41-picker_69f456ba80fac\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1950\" data-end-year=\"2030\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"01\/01\/1950\" data-end-date=\"12\/31\/2030\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"9d782bbdd2\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/1131\" \/><input type=\"hidden\" name=\"form_id\" value=\"69\"><input type=\"hidden\" name=\"page_id\" value=\"1131\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/forms.dive.gr\/index.php\/nehp\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1131","page","type-page","status-publish","hentry","entry"],"_links":{"self":[{"href":"https:\/\/forms.dive.gr\/index.php\/wp-json\/wp\/v2\/pages\/1131","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/forms.dive.gr\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/forms.dive.gr\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/forms.dive.gr\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/forms.dive.gr\/index.php\/wp-json\/wp\/v2\/comments?post=1131"}],"version-history":[{"count":1,"href":"https:\/\/forms.dive.gr\/index.php\/wp-json\/wp\/v2\/pages\/1131\/revisions"}],"predecessor-version":[{"id":1133,"href":"https:\/\/forms.dive.gr\/index.php\/wp-json\/wp\/v2\/pages\/1131\/revisions\/1133"}],"wp:attachment":[{"href":"https:\/\/forms.dive.gr\/index.php\/wp-json\/wp\/v2\/media?parent=1131"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}